When Treshon Cousin arrived at the St. Tammany Parish jail in the early evening of June 28, the 22-year-old mother of two told screeners she had been in a fight the night before and suffered an injury to her hip.

She also said she might be pregnant.

But she never told screeners she was having suicidal thoughts, according to a Sheriff’s Office investigative report, even though she was asked that question by four different people, one of them a nurse.

The question, as listed on the jail’s standard intake questions posted in the jail, is phrased “Thoughts of killing/hurting yourself or anyone else?” Each time, Cousin’s answer was no, according to interviews conducted by Detective Daniel Buckner for an investigative report.

But Cousin did kill herself, less than two hours after she arrived at the jail.

Video of the holding cell viewed by the New Orleans Advocate shows she got up from a concrete bench where she had been sitting, alone, with her head on her knees. She paced briefly, looking at the phone and then glancing down at another nearby bench.

Moments later, she removed the receiver and wrapped the phone cord around her neck, dropping to her knees and maneuvering her legs out from under her body. Deputies found her hanging there about 20 minutes later. Correctional officers and medical staff immediately began working to revive her, removing the phone cord, putting an oxygen mask over her face, performing CPR and using an external defibrillator.

By the time Cousin left the jail in an ambulance, her heartbeat had been restored, according to Buckner’s report. But the young woman never regained consciousness. On July 1, her family took her off life support at St. Tammany Parish Hospital. The official cause of death, according to the St. Tammany Parish Coroner’s Office, was asphyxia due to hanging. The manner of death: suicide.

Earlier findings

Cousin’s death occurred a month and a half before St. Tammany Parish sheriff’s officials signed an agreement with the Department of Justice Civil Rights division aimed at improving suicide prevention at the jail and conditions for mentally ill prisoners. The agreement stems from a July 12, 2012, findings letter that concluded jail conditions violated the constitutional rights of prisoners and that St. Tammany was “deliberately indifferent to prisoners’ serious mental health needs, including suicide prevention and medication management.”

Among other things, the DOJ had blasted the jail for its use of tiny cells called “squirrel cages” for suicidal prisoners — a practice that the jail has dropped. The DOJ also criticized the jail for using licensed practical nurses rather than registered nurses to conduct screenings, saying they are not adequately trained. Cousin was screened by an LPN.

The recent agreement with the DOJ does not address the use of LPNs, but it does provide a lengthy list of training requirements to improve staffers’ ability to prevent suicides.

The agreement, signed Aug. 15, calls for a Morbidity and Mortality Review Committee to look into each suicide or serious suicide attempt within 30 days and make recommendations for changes, if needed, involving anything from the physical plant to training and procedures.

It’s not clear whether Cousin’s death has spurred any changes at the jail. But shortly after the incident, Sheriff Jack Strain said that his department was “working closely with the Department of Justice on a complete review of the events of Friday night.”

The Sheriff’s Office did not answer questions about whether a committee has reviewed Cousin’s death, as called for in the agreement.

At the time of her death, Strain noted that there were no signs that Cousin, who was brought in on a minor charge, was a suicide risk, and she was not treated as one. She was picked up on an attachment for contempt of court — failure to pay fines from an assault charge stemming from a high school fight.

On the jail’s videotape, Cousin’s behavior and demeanor reveal no obvious signs of emotional turmoil. Visually, her interactions with deputies are unremarkable. She can be seen talking and even laughing with the six other women who were in the holding cell when she arrived.

Attempts to make contact

But the videotape also shows she made many futile efforts to contact family and friends using the holding cell telephone. Buckner’s report notes 17 calls, none of which were answered. Buckner interviewed each of the six other inmates who were initially in the holding cell with Cousin. Each mentioned Cousin’s failed efforts to reach someone by phone. Two of the women described her as “aggravated” at not being able to contact anyone; another said she was “upset.” But to a person, they said that Cousin did not seem depressed that night, and that she made no suicidal statements.

Mindi McQueen recalled Cousin as happy, “smiling and talking about her baby.” She said she told Cousin that she wouldn’t be there long — an opinion that McQueen said was backed up by a deputy who said Cousin was unlikely to be moved from the holding cell to a dorm. Another woman in the cell described Cousin as “calm,” and just trying to make phone contact.

Only one person who shared a cell with Cousin that night drew a more troubling picture. Nancy Gaines said that Cousin was acting “crazy” and was angry about being in jail. To her, Cousin appeared to be “on edge” as if she was “coming off drugs,” according to Buckner’s interview.

In fact, Cousin did have drugs in her system that night — marijuana and methamphetamine, according to jail personnel who took a urine sample from her when she first arrived.

She also was going through a rough time in her personal life. Her father, Michael Cousin, told Buckner that his daughter had recently split up with her boyfriend, Julius McFarland, the father of her infant son. He said she was upset about the end of the relationship and that, on the day before her arrest, she had been put out of the residence the couple shared.

Cousin was arrested after McFarland called the Sheriff’s Office to complain that she had entered their home without permission. He wanted her arrested for burglary, according to Buckner’s report. But a deputy on the scene told McFarland that he had not used proper eviction procedures and that Cousin still had belongings in the house, so he wouldn’t arrest her for burglary.

But in the course of their investigation, deputies discovered there was an active attachment for Cousin stemming from a contempt of court charge, and they went to the house where she was staying with a friend to arrest her.

The day after Cousin’s death, her father and stepmother told the New Orleans Advocate that she had never suffered from depression or expressed suicidal thoughts.

“My daughter is a fighter,” Michael Cousin said then. “She’s overcome a lot of adversity in her life.”

But Buckner’s interview with Cousin’s father shows another side. The report quotes Michael Cousin as saying that his daughter talked of killing herself before the birth of her second child — something he said he persuaded her not to do. A friend, identified in the report only by her first name, Candace, said Cousin was upset about her relationship problems and had previously been on medication for depression — medication she stopped taking before her son’s birth in January.

Michael Cousin declined to be interviewed for this story.

Of the nine questions Treshon Cousin was asked at the jail, only one dealt with suicidal feelings. Others focused on her physical health and other circumstances, from whom she lived with to whether she had any enemies in jail.

Screening questions

The DOJ agreement calls for more extensive questioning of incoming prisoners. For example, it lists questions about past suicidal ideas or suicide attempts, prior mental health treatment, history of suicidal behavior by family or close friends. It also lists questions about recent significant loss, such as the death of a family member or close friend.

Christine Tartaro, a professor of criminal justice at Richard Stockton College of New Jersey and an expert in jail suicides, said the vast majority of people give some sort of signal of suicidal intentions, including behavioral changes. That could include calm behavior on the part of someone who is normally more keyed up, she said. But knowing what’s normal for that particular person is important to picking up on those signals.

Tartaro described hanging as the most common method of suicide in institutional settings, simply because serviceable tools — a heavy phone cord or a bed sheet — tend to be available. It is also highly lethal, she said.

St. Tammany Parish Jail has special cells for prisoners identified as suicidal that provide constant supervision — a change that replaced the highly criticized squirrel cages. But because Cousin was not flagged as suicidal, she wasn’t placed in one of those cells.

Tartaro said that it’s important to know what the jail’s procedures are for monitoring holding cells, and that is unclear. The Sheriff’s Office did not answer requests from the New Orleans Advocate to see its policies and procedures manual, nor did officials answer a question about how often the holding cell is supposed to be checked.

The night Cousin died, the cell was not checked for about 45 minutes. The women who shared the cell with her were taken to the dorm at 8:01 p.m., at which time Cousin was left alone. She wrapped the phone cord around her neck 23 minutes later, and she was not discovered until 8:45 p.m.

According to Buckner’s report, the deputy who was handling the main control panel at the time of Cousin’s death, Deputy Patrick McKnight, had relieved another deputy there at around 8 p.m. The station is a control board with switches that open and close security access points and passageways throughout the booking and intake area, according to Sheriff’s Office spokesman Capt. George Bonnett.

“Deputy McKnight stated he was unaware there were any females remaining in the holding cell because he was previously informed all females were being reassigned to the dorm,” Buckner’s report said.

McKnight told Buckner he was instructed to conduct inmate bookings to help the booking officer. When he returned to his station, “Deputy McKnight observed Ms. Cousin in the holding cell and stated it appeared as if she was squatting and had the phone resting on her shoulder. Deputy McKnight looked again and realized Ms. Cousin was suspended from the phone by the cord around her neck.”